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=' ~- ~ ~ III IIIIIIIIIIIIIIII <br />999 <br />~~~~av~~ <br />Permit No: 77-557 <br />Anniversary Date: February 22 MAR 1 11882 <br />MINED LAND RECLAMATIOAI <br />Cole. Dept. of A~?t!rzl Resa!~rce~ <br />Operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />® ti on Division for annual fees due <br />Annual Report <br />Map <br />Remarks <br />Ir Ri~1. ~~.wfM~A J4s~! ~ /`sNVLn <br /> <br /> <br /> <br />Signed, <br /> <br />